A nurse is educating a client who has a transient ischemic attack (TIA). The client says to the nurse, "I don't understand why I need to take medication if it was just a mini-stroke." How should the nurse respond?
"You need to take medication to prevent blood clots from forming in your arteries."
"You need to take medication to reduce the swelling in your brain after a stroke."
"You need to take medication to lower your blood pressure and cholesterol levels."
"You need to take medication to control your blood sugar and prevent diabetes."
The Correct Answer is A
Choice A reason:
This is a correct answer. The nurse should explain to the client that they need to take medication to prevent blood clots from forming in their arteries after a TIA. A TIA is caused by a temporary blockage in a cerebral artery that reduces blood flow to the brain tissue and causes stroke-like symptoms that resolve within 24 hours. However, a TIA increases the risk of having a full-blown ischemic stroke in the future, which can cause permanent brain damage or death. Therefore, antiplatelet or anticoagulant medications are prescribed to prevent clot formation and reduce stroke risk.
Choice B reason:
This is an incorrect answer. The nurse should not tell the client that they need to take medication to reduce the swelling in their brain after a stroke. This is not the purpose of medication therapy for a TIA. A TIA does not cause significant swelling or edema in the brain, unlike a hemorrhagic stroke, which involves bleeding into the brain tissue or subarachnoid space. Swelling in the brain can increase intracranial pressure (ICP) and cause further brain damage or herniation.
Choice C reason:
This is an incorrect answer. The nurse should not tell the client that they need to take medication to lower their blood pressure and cholesterol levels. This is not the immediate purpose of medication therapy for a TIA, although it may be part of the long-term management of stroke risk factors. High blood pressure and high cholesterol are common causes of atherosclerosis, which is the buildup of plaque in the arterial walls that narrows the lumen and reduces blood flow. Atherosclerosis can lead to ischemic stroke if a piece of plaque breaks off and blocks a cerebral artery.
Choice D reason:
This is an incorrect answer. The nurse should not tell the client that they need to take medication to control their blood sugar and prevent diabetes. This is not the immediate purpose of medication therapy for a TIA, although it may be part of the long-term management of stroke risk factors. High blood sugar and diabetes are common causes of endothelial dysfunction, which is the impairment of the inner lining of the blood vessels that regulates blood flow and clotting. Endothelial dysfunction can lead to ischemic stroke if a blood clot forms and blocks a cerebral artery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
This is an incorrect answer. Elevating the head of the bed to 30 degrees is not an appropriate intervention for a client who has a hemorrhagic stroke. Elevating the head of the bed can lower blood pressure and reduce cerebral perfusion pressure, which can worsen brain ischemia and injury.
Choice B reason:
This is an incorrect answer. Administering aspirin as prescribed is not an appropriate intervention for a client who has a hemorrhagic stroke. Aspirin is an antiplatelet agent that inhibits
the clotting of blood and increases the risk of bleeding in the brain or elsewhere. Aspirin is contraindicated for clients who have a hemorrhagic stroke and may worsen their condition.
Choice C reason:
This is a correct answer. Monitoring blood pressure and keeping it within normal range is an appropriate intervention for a client who has a hemorrhagic stroke. Blood pressure is a major factor that affects the severity and outcome of hemorrhagic stroke. High blood pressure can increase the bleeding and ICP, while low blood pressure can reduce cerebral perfusion and oxygenation. The nurse should monitor blood pressure frequently and administer antihypertensive or vasopressor medications as prescribed to maintain optimal blood pressure.
Choice D reason:
This is an incorrect answer. Performing passive range of motion exercises is not an appropriate intervention for a client who has a hemorrhagic stroke. Passive range of motion exercises can increase ICP and bleeding by stimulating the sympathetic nervous system, which increases blood pressure and cerebral blood flow. The nurse should avoid any activity that can increase ICP or bleeding in the acute phase of hemorrhagic stroke.
Correct Answer is ["A","D","E"]
Explanation
Choice A reason:
This is a correct answer. Sudden severe headache is a common symptom of hemorrhagic stroke, which is caused by bleeding into the brain tissue or subarachnoid space. The headache may be described as "the worst headache of my life" or "thunderclap headache".
Choice B reason:
This is an incorrect answer. Facial drooping is a common symptom of ischemic stroke, which is caused by a blockage in a cerebral artery that reduces blood flow to the brain tissue. Facial drooping may affect one side of the face and cause asymmetry or difficulty smiling.
Choice C reason:
This is an incorrect answer. Slurred speech is another common symptom of ischemic stroke, which affects the areas of the brain responsible for language and communication. Slurred speech may also be accompanied by aphasia, which is difficulty understanding or expressing words.
Choice D reason:
This is a correct answer. Nuchal rigidity is a common symptom of subarachnoid hemorrhage, which is a type of hemorrhagic stroke that involves bleeding into the space between the brain and the meninges. Nuchal rigidity refers to stiffness or pain in the neck when flexing or extending it.
Choice E reason:
This is a correct answer. Hemiparesis is a common symptom of both ischemic and hemorrhagic stroke, which affect the motor areas of the brain and cause weakness or paralysis on one side of the body. Hemiparesis may affect the face, arm, leg, or trunk on the opposite side of the brain injury.
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